MEDICAID PLANNING QUESTIONNAIRE

This form is very important. Your accuracy and completeness in responding will help us represent you.

A.CLIENT INFORMATION

Name: ______ / Date: ______
Address: ______
City: ______ / State: ______ / Zip: ______
Home Phone: ______ / Cell: ______
E-Mail:______ / Fax: ______

B. PERSONAL INFORMATION

Name: ______ / Date of Birth: ______
Address: ______
City: ______ / State: ______ / Zip: ______
Home Phone: ______ / Cell: ______
U.S. Citizen? / Yes / No / Wartime? / Yes / No
Veteran? / Yes / No / Service Related Disability? / Yes / No

C. CHILDREN

Full Name / Address w/ Zip Code / Phone # / Email.
1.
2.
3.
4.
Are any of your children disabled or receiving public benefits? / Yes / No
Do any of your children live with you? / Yes / No
If you answered “yes” to any of the above questions, please explain:

D. GRANDCHILDREN (If applicable)

How many grandchildren? / ______
Are any grandchildren disabled? / Yes No

E. MEDICAL INFORMATION

1.HEALTH

Diagnosis? / ______
Prognosis? / ______
Course of Treatment? / ______
Activities of Daily Living / (Please circle all which require assistance)
Medication / Cognition / Feeding / Dressing / Mobility / Toileting
Where currently resides? ______
Is this skilled nursing facility? / Yes / No / Date Entered: / ______
Is this an assisted living facility? / Yes / No / Date Entered: / ______
If not, is placement imminent? / Yes / No / When: / ______
Where did applicant reside prior to SNF or AL? ______

2.Physicians

Primary Dr. / ______
Address: / ______
City, State, Zip / ______
Telephone / ______

3.IF UNDER 65:

Have you ever received SSI? / Yes / No
Have you ever received SSDI? / Yes / No
Have you ever had a disability determination by a state agency? / Yes / No

F. MONTHLY INCOME

Social Security Benefits (gross) / $
Medicare Part B Deduction / <$ >
Retirement Benefits* (gross) Please list the source and type of benefit.
1. / $
2. / $
3. / $
VA Benefit: Disability / $
Service Related / $
Annuity Income / $
Rental Income / $
Investment Income / $
Other Income (identify source) / $
1. / $
2. / $
TOTAL MONTHLY INCOME / $

*For any retirement benefits, including a pension, please list the gross benefit amount, including any monies taken out for federal income taxes, health insurance, dues or any other reason.

Do you expect the retirement benefits amount to increase in the future? YesNo

(other than cost of living increases)

G. MONTHLY COST OF SKILLED NURSING/ASSISTED LIVING (if applicable)

Monthly Skilled Nursing/Assisted Living cost? / $
Monthly Prescription Cost / $
Monthly Incontinence Cost / $
Monthly Other Cost / $
Total Monthly Cost / $
The nursing home is paid through the month of

H. Gifts

Please list any gifts made to an individual, a group of individuals or to a trust within the past 5 years:
Recipient / Date / Amount / $
Recipient / Date / Amount / $
Recipient / Date / Amount / $
Recipient / Date / Amount / $
Recipient / Date / Amount / $
Have you ever filed a Federal Gift Tax Return? / Yes / No
  1. ASSETS

Assets / Value / Assets / Value
Residence / $ / Stocks Not Held by Broker / $
Other Real Estate / $ / Bonds Not Held by Broker / $
Automobile / $ / Annuities / $
Additional Automobile(s) / $ / Cash Value of Life Insurance / $
Checking Account(s) / $ / IRAs / $
$ / 401K or other tax-deferred acct. / $
Savings Account(s) / $ / Funeral/Burial Plan* / $
$ / Promissory Notes / $
Money Market Accts / $ / Business Interests / $
Certificates of Deposit / $ / Copyrights or Royalties / $
Brokerage Account / $ / Other / $
Mutual Funds Not Held by Broker / $ / Other / $
Totals / $

*if you have a funeral or burial plan, is the plan revocable or irrevocable? ______

What did you pay for your current home, including improvements? / $______
Address of any real property other than personal residence:
(1) Street ______
City / ______/ State / ______/ Zip / ______
What did you pay for this property, including any improvements? / $______
(1) Street ______
______/ State / ______/ Zip / ______
What did you pay for this property, including any improvements? / $______

J. LIABILITIES

Amount of Liability
Mortgage / $______
2nd Mortgage / $______
Line of Credit / $______
Credit Cards / $______
Auto Loan / $______
Medical Bills / $______
Tax Liabilities / $______

K. LONG-TERM CARE INSURANCE

Owner / Company / Policy No. / Daily Benefits / Benefit Limit
(1) / $ / $
(2) / $ / $

L. LIFE INSURANCE

1. / Company / Policy Number
Owner / Term or Whole Life
Beneficiary / Monthly Premiums
Face Value / *Cash Value
2. / Company / Policy Number
Owner / Term or Whole Life
Beneficiary / Monthly Premiums
Face Value / *Cash Value
3. / Company / Policy Number
Owner / Term or Whole Life
Beneficiary / Monthly Premiums
Face Value / *Cash Value

*It is very important to know the cash value and the death benefit of your life insurance policy. To obtain the cash value of the policy, please call your insurance agent, or call the insurance company directly.

M. WILLS AND ADVANCE DIRECTIVES

Do you have any of the following documents?

Last Will and Testament / Yes No
General Power of Attorney (financial) / Yes No
Power of Attorney for Health Care / Yes No
Advance Directive (Living Will) / Yes No
Trusts of any kind / Yes No
Other, Please describe:

N. REFERRAL

Who may we thank for referring you to this office?

Name: / ______
Address: / ______
City, State, Zip / ______

How were you referred to this Office?

Please circle one: / ______
Website/Internet / ______
Yellow Pages Advertising / ______
Professional / ______
Attended Seminar / ______
Other: / ______

O. CERTIFICATION

The undersigned herby represents to the law office of Procter, Callahan & Liska, LLC, and each of its attorneys, that the information contained in this intake form is accurate and complete to the best of my knowledge. The undersigned further understands that the law firm and its individual lawyers will rely on this information and that if the information contained herein is inaccurate or incomplete, the recommendations may not be appropriate.

Signature of Client or Client Representative: / ______

Procter, Callahan & Liska, LLC(970) 266-9669Page 1